OMIG Identifies Millions in Bad Dental Payments

Patients who have no teeth do not need fillings or other restoration. And dentists who bill for such services should not get paid by the Medicaid program, according to the Office of the Medicaid Inspector General (OMIG).

Under the direction of Medicaid Inspector General James C. Cox, the OMIG conducted a sophisticated data matching review that examined not only alleged restorative work being billed on patients who were edentulous (i.e., have no teeth), but also looked at payments where consultation procedures were done without referring provider information and where the Medicaid program was double-billed for recipients living in skilled nursing facilities. OMIG issued 158 final reports on this issue for a total of $3,174,102.

“Medicaid payments should never be made for restorative dental work done on people who have no teeth,” said Cox. “The Medicaid information for these patients is being exploited for financial gain, and that is unacceptable.”

Patients can lose all of their teeth for a number of reasons—as the result of accidents, age, or poor dental hygiene. Such individuals would be candidates for dentures, not restorative procedures, such as fillings or root canals. OMIG identified payments for 465 toothless patients.

Dental patients who need specialty care can be referred to dentists who have developed specific skills. Referrals must be documented to guard against dentists who might refer patients to themselves without preparing proper paperwork to hide that fact. OMIG also found that payments without appropriate referring provider information accounted for 75,392 patients.

Billing for residents of skilled nursing facilities is another problem. When an individual is a resident of a skilled nursing facility, his or her dental needs are already accounted for in the rate paid to the nursing home, so the nursing home itself is responsible for paying the dentist’s bill. When a dentist bills the Medicaid program separately for a SNF resident, the Medicaid program is paying for what the nursing home has already received through the normal daily rate. OMIG discovered that double-billed dental services accounted for $998,711 for 1,962 nursing home residents.

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The mission of the New York State Office of the Medicaid Inspector General is to enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices in the Medicaid program and recovering improperly expended Medicaid funds while promoting high-quality patient care.